Provider Demographics
NPI:1831133727
Name:BOLTON, HEATHER DIANA (PA)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:DIANA
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:HEATHER
Other - Middle Name:DIANA
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3322
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37088
Mailing Address - Country:US
Mailing Address - Phone:615-449-4151
Mailing Address - Fax:615-449-1994
Practice Address - Street 1:307 F WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087
Practice Address - Country:US
Practice Address - Phone:615-449-4151
Practice Address - Fax:615-449-1994
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3663056Medicare PIN